University of Santo Tomas

University of Santo Tomas Hospital

Department of Medicine

IM REVALIDA PEARLS

March 21, 2019

What to study?
 COUGH
FEVER CHEST PAIN EDEMA
DYSPNEA JAUNDICE
ABDOMINAL PAIN ANEMIA
DYSURIA
 NEPHRO
PULMO
CARDIO ENDO
HEMA
GIID
RHEUMA
DYSPEPSIA/INDIGESTION.
CC: Indigestion/Dyspepsia

HISTORY
§ Substernal warmth that moves toward the neck? à HEARTBURN
§ Exacerbated by meals and awakens the patient?
§ Pharyngitis, asthma, cough, bronchitis, hoarseness, and chest pain?

PHYSICAL EXAMINATION
§ Normal.
§ Pharyngeal erythema and wheezing may be noted
§ Poor dentition.

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Indigestion/Dyspepsia

GERD FUNCTIONAL DYSPEPSIA PUD

Heartburn, regurgitation
Bothersome postprandial fullness,
early satiety, or epigastric pain or
burning with symptom onset at least
6 months before diagnosis in the
absence of organic cause
Epigastric pain described
as a burning or gnawing
discomfort

DU: occurs 90 min to 3 h after a meal; relieved by antacids or food

GU: discomfort may actually be precipitated by food

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Indigestion/Dyspepsia

DIAGNOSTICS
Patients with typical GERD do not need further evaluation and are treated empirically.

4-week trial of an acid-suppressing medication such as a proton pump inhibitor (PPI)

is recommended

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Indigestion/Dyspepsia

TREATMENT
Reassurance.
Insulting agent should be stopped.
Patients with GERD should limit ethanol, caffeine, chocolate, and tobacco.
Other measures: low-fat diet, avoiding snacks before bedtime, and elevating
the head of the bed.
Reduce intake of fat, spicy foods, caffeine, and alcohol.

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Indigestion/Dyspepsia

TREATMENT
(1) avoidance of foods that reduce LES pressure, making them
“refluxogenic” (these commonly include fatty foods, alcohol, spearmint,
peppermint, and possibly coffee and tea);
(2) avoidance of acidic foods that are inherently irritating (citrus fruits,
tomato-based foods)
(3) adoption of behaviors to minimize reflux and/or heartburn.

Harrison’s Principles of Internal Medicine, 20 th Edition

 COUGH.
Triggered by stimulation of
sensory nerve endings that are
thought to be primarily rapidly
adapting receptors and C fibers.

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Cough

HISTORY ACUTE SUBACUTE CHRONIC

<3 weeks 3-8 weeks >8 weeks
Most commonly due Tracheobronchitis, as cardiopulmonary
to a respiratory tract in pertussis or diseases, including
infection, aspiration, “postviral tussive those of
or inhalation of syndrome.” inflammatory,
noxious chemicals or infectious, neoplastic,
smoke. and cardiovascular
etiologies.

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Cough

DISEASE RESOURCE
Community-Acquired Philippine Clinical Practice Guidelines for the
Pneumonia Diagnosis , Empiric, Management and Prevention
of Community-Acquired Pneumonia in
Immunocompetent Adults 2016 Update
Pulmonary Tuberculosis Clinical Practice Guidelines for the Diagnosis,
Treatment, Prevention and Control of Tuberculosis
in Adult Filipinos 2016 Update
Bronchial Asthma GINA
COPD GOLD

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Cough

PNEUMONIA?
Notes:
§ Start antibiotics as soon as possible after the diagnosis.
§ Drug of choice for Low-risk CAP: Amoxicillin
§ If Low-risk CAP, with stable comorbid illness: B-lactam with B-lactamase inhibitor
combinations or second generation cephalosporins with or without extended
macrolide
CC: Cough

CHRONIC COUGH
Notes:
§ In virtually all instances, evaluation of chronic cough merits a chest radiograph.
§ Chronic productive cough, examination of expectorated sputum is warranted.

NORMAL CXR?
Use of an ACE inhibitor; postnasal drainage; gastroesophageal
reflux; and asthma account for >90% of cases of chronic cough
with a normal or noncontributory chest radiograph

Harrison’s Principles of Internal Medicine, 20 th Edition

 NON-SPECIFIC INFECTIONS OF THE
UPPER RESPIRATORY TRACT (URTI)
They are identified by a variety of descriptive names, including acute infective
rhinitis, acute rhinopharyngitis/nasopharyngitis, acute coryza, and acute nasal
catarrh, as well as by the inclusive label common cold.
§ Rhinovirus:most common cause of URI (~30–40% of cases)
§ The principal signs and symptoms of nonspecific URI include rhinorrhea (with or
without purulence), nasal congestion, cough, and sore throat.
§ Other manifestations: fever, malaise, sneezing, lymphadenopathy, and hoarseness

Harrison’s Principles of Internal Medicine, 20 th Edition

 NON-SPECIFIC INFECTIONS OF THE
UPPER RESPIRATORY TRACT (URTI)
They are identified by a variety of descriptive names, including acute infective
rhinitis, acute rhinopharyngitis/nasopharyngitis, acute coryza, and acute nasal
catarrh, as well as by the inclusive label common cold.
§ Cough secondary to URI frequently lasts 2–3 weeks
§ Findings on physical examination are frequently nonspecific and unimpressive.
§ Antibiotics have no role in the treatment of uncomplicated nonspecific URI

Harrison’s Principles of Internal Medicine, 20 th Edition

 DYSURIA.
Pain that occurs during
urination, is commonly
perceived as burning or
stinging in the urethra.

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Dysuria

HISTORY
At least one symptom of UTI (dysuria, frequency, hematuria, or back pain)
and without complicating factors, the probability of acute cystitis or
pyelonephritis is 50%.
CC: Dysuria

HISTORY
CC: Dysuria

HISTORY
CC: Dysuria

HISTORY
CC: Dysuria
 DIARRHEA.

Harrison’s Principles of Internal Medicine, 20 th Edition

CC: Diarrhea
FEVER
Maximal normal oral temperature:
.§ 37.2°C (98.9°F) at 6 a.m.
§ 37.7°C (99.9°F) at 4 p.m.
 CHEST PAIN.

Harrison’s Principles of Internal Medicine, 20 th Edition

CHEST PAIN.
CC: Chest Pain

DIAGNOSTICS
1. ECG
2. Chest Radiograph
3. Cardiac Biomarkers
4. 2D Echo with Doppler Studies
 DYSPNEA.
Subjective experience of breathing
discomfort that consists of
qualitatively distinct sensations
that vary in intensity.

Harrison’s Principles of Internal Medicine, 20 th Edition

 EDEMA.

Harrison’s Principles of Internal Medicine, 20 th Edition

 JOINT PAINS.

Harrison’s Principles of Internal Medicine, 20 th Edition

 OSTEOARTHRITIS
Most common type of arthritis.
§ Commonly affected joints include the hip, knee,
and first metatarsal phalangeal joint (MTP) and
cervical and lumbosacral spine.
§ In the hands, the distal and proximal
interphalangeal joints and the base of the thumb
§ Usually spared are the wrist, elbow, and ankle.
 OSTEOARTHRITIS
Most common type of arthritis.
§ Commonly affected joints include the hip, knee,
and first metatarsal phalangeal joint (MTP) and
cervical and lumbosacral spine.
§ In the hands, the distal and proximal
interphalangeal joints and the base of the thumb
§ Usually spared are the wrist, elbow, and ankle.
 OSTEOARTHRITIS
Most common type of arthritis.
 OSTEOARTHRITIS
Most common type of arthritis.
§ Joint pain from OA is primarily activity-
related in the early stages of the disease.
Pain comes on either during or just after
joint use and then gradually resolves.
§ OA is the most common cause of chronic
knee pain in persons aged >45, but the
differential diagnosis is long.
 OSTEOARTHRITIS
Most common type of arthritis.
§ No blood tests are routinely indicated for
workup of patients with OA unless
symptoms and signs suggest inflammatory
arthritis.
§ X-rays are indicated to evaluate the
possibility of OA only when joint pain and
physical findings are not typical of OA or
if pain persists after inauguration of
treatment effective for OA
 OSTEOARTHRITIS
The goals of the treatment of OA are to
alleviate pain and minimize loss of physical
function.
§ The simplest treatment for many patients is to
avoid activities that precipitate pain.
§ Since the loading effect of each pound of
weight is multiplied across the knee three- to
sixfold, each pound of weight loss may have
a commensurate multiplier effect.
§ Correction of misalignment.
§ NSAIDs are the most popular drugs to treat
osteoarthritic pain.
 GOUT
Metabolic disease that most often affects middle-aged to elderly men and
postmenopausal women. It results from an increased body pool of urate with
hyperuricemia
§ Acute arthritis is the most common early clinical manifestation of gout.
§ Usually, only one joint is affected initially.
§ The metatarsophalangeal joint of the first toe often is involved
§ Inflamed Heberden’s or Bouchard’s nodes may be a first manifestation
§ The first episode frequently begins at night with dramatic joint pain and swelling.
 GOUT
Metabolic disease that most often affects middle-aged to elderly men and
postmenopausal women. It results from an increased body pool of urate with
hyperuricemia
§ Joints are warm, red, and tender, with a clinical appearance that often mimics that
of cellulitis.
§ Early attacks tend to subside spontaneously within 3–10 days, and most patients
have intervals of varying length with no residual symptoms until the next episode.
§ Several events may precipitate acute gouty arthritis: dietary excess, trauma, surgery,
excessive ethanol ingestion, hypouricemic therapy, and serious medical illnesses
such as myocardial infarction and stroke.
 GOUT
Metabolic disease that most often affects middle-aged to elderly men and
postmenopausal women. It results from an increased body pool of urate with
hyperuricemia
§ Even if the clinical appearance strongly suggests gout, the presumptive diagnosis
ideally should be confirmed by needle aspiration of acutely or chronically involved
joints or tophaceous deposits.
§ Synovial fluid leukocyte counts are elevated from 2000 to 60,000/µL. Effusions
appear cloudy due to the increased numbers of leukocytes.
§ Serum uric acid levels can be normal or low at the time of an acute attack.
 GOUT
Metabolic disease that most often affects middle-aged to elderly men and
postmenopausal women. It results from an increased body pool of urate with
hyperuricemia
§ The mainstay of treatment during an acute attack is the administration of anti-
inflammatory drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs),
colchicine, or glucocorticoids.
§ Ultimate control of gout requires correction of the basic underlying defect: the
hyperuricemia.
HYPOTHYROIDISM
HYPOTHYROIDISM
 HYPOTHYROIDISM
Daily replacement dose of levothyroxine is usually 1.6 µg/kg
body weight (typically 100–150 µg), ideally taken at least 30 min
before breakfast
§ Adult patients under 60 years old without evidence of heart
disease may be started on 50–100 µg levothyroxine (T4) daily.
§ Patients may not experience full relief from symptoms until 3–6
months after normal TSH levels are restored.
§ Adjustment of levothyroxine dosage is made in 12.5- or 25-µg
increments if the TSH is high
§ Once full replacement is achieved and TSH levels are stable,
follow-up measurement of TSH is recommended at annual
intervals.
HYPERTHYROIDISM
HYPERTHYROIDISM
 HYPERTHYROIDISM
The hyperthyroidism of Graves’ disease is treated by
reducing thyroid hormone synthesis, using an
antithyroid drug, or reducing the amount of thyroid
tissue with radioiodine (131I) treatment or by
thyroidectomy.
ADD-ONS.
30F Vaginal Pruritus
§ 3-day history of vaginal pruritus.
§ PMH: Hypertensive, IFG
§ Personal History: Secondhand smoke exposure (husband)
§ Physical Examination was unremarkable.

§ Hypertension St II
A> VULVAR FOLLICULITIS
§ IFG
§ Smoking Cessation
 HYPERTENSION

Harrison’s Principles of Internal Medicine, 20 th Edition

 HYPERTENSION

Harrison’s Principles of Internal Medicine, 20 th Edition

 OBESITY

Harrison’s Principles of Internal Medicine, 20 th Edition

 DIABETES MELLITUS

Harrison’s Principles of Internal Medicine, 20 th Edition

 DIABETES MELLITUS

Harrison’s Principles of Internal Medicine, 20 th Edition

 DIABETES MELLITUS

Harrison’s Principles of Internal Medicine, 20 th Edition

 DIABETES MELLITUS

Harrison’s Principles of Internal Medicine, 20 th Edition

 University of Santo Tomas
University of Santo Tomas Hospital
Department of Medicine

THANK YOU.

PREPARED BY:
Nenuel Angelo B. Luna, MD